Difference between revisions of "Veterans Health Information Systems and Technology Architecture (VistA)"

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# http://www.virec.research.va.gov/DataSourcesName/VISTA/VistA.htm
 
# VistA Online Training Web Site: http://vaww.vistau.med.va.gov/vistau/default.htm
 
# Brown, SH, Lincoln MJ et al. [http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T7S-47CHD1B-1&_user=5674961&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000003838&_version=1&_urlVersion=0&_userid=5674961&md5=ff31f151f996d7eb51044546eb0fe2ec VistA - U.S. Department of Veterans Affairs national-scale HIS]. International Journal of Medical Informatics. 2003; 69:135-156.
 
 
# Longman, Phillip. Best Care Anywhere – Why VA Health Care is Better Than Yours. 2007. Poli Point Press
 
# Longman, Phillip. Best Care Anywhere – Why VA Health Care is Better Than Yours. 2007. Poli Point Press
 
# 2008_2009_VistAHealtheVet_Monograph_FC_0309, http://www.va.gov/VISTA_MONOGRAPH/docs/2008_2009_VistAHealtheVet_Monograph_FC_0309.doc
 
# 2008_2009_VistAHealtheVet_Monograph_FC_0309, http://www.va.gov/VISTA_MONOGRAPH/docs/2008_2009_VistAHealtheVet_Monograph_FC_0309.doc

Revision as of 00:25, 29 January 2015


History

Information technology has been utilized by the Veterans Health Administration (VHA) to fulfill its purpose effectively for quite some time.).[1] In the late 1970's, the Office of Data Management and Telecommunications (ODM&T) was given the job to computerize the VA nationwide. While the centralized computerization efforts were being implemented in batch transactions-based systems, local facilities acquired computers in a way higher rate than ODM&T initiatives. Local management was interested in conducting research and on finding ways to improve care and efficiency through computers systems and they did not want to wait for the lengthy centralized developments to be implemented. [2]

In 1977, the Department of Medicine & Surgery, the predecessor of the VHA, created the Computer-Assisted System Staff (CASS) Office. They involved clinical experts in the process of computerization of the medical centers, and avoided the lengthy traditional administrative process used by ODM&T. Local applications were developed by language programmers using the Massachusetts General Hospital Utility Multi-Programming System (MUMPS), or alternatively, M programming language. VA’s Decentralized Hospital Computer Program (DHCP) included applications for administration, mental health, radiology and dietetics. VA medical center and CASS Office personal also focused on re-usability and the adherence to an active data dictionary, two characteristics that were declared in a conference in December 1982. [2]

The ODM&T tried to shut down development, but DHCP developers continued their work. DHCP developers referred to themselves as the “Hard Hats” and worked secretly on DHCP against direct orders from ODM&T. One of the reasons for the success of DHCP was that its robust infrastructure enabled individuals to develop independent applications. This allowed developers to work on DHCP applications separately while they waited for approval to put their modules together into a cohesive system (4). Eventually VA Administrator Robert Nimmo approved a policy giving facility directors the power to choose computer applications in 1982. A first group of 25 sites and 11 applications was in place by 1983. These were followed by up to 100 sites in year 1985.

VistA’s applications share a common infrastructure that integrates them at the database level. Though the enterprise solution allows flexible local control over content and configuration (meeting specific user’s needs), a set of common data dictionary, database standards, programming conventions and technical reviews avoid incompatibility between the different applications. When a problem of different site-specific data dictionary appears, a national standard dictionary is used as Interlingua to fix the problem. [2]

The common infrastructure support, reproduce and advance-single centered successes, incentivizing local participation and development while assuring an automated output of local systems that provide system wide data to the administrator. The unique patient identifier (Mater Patient Index/Patient demographic) and a system single sign-on contribute to VistA’s functional capacity as a single system. [2]

Several factors led to the VA’s national-scale hospital information system, including veterans and employee’s frequent regional mobility and shared services and maintenance expenses. Similar systems also facilitate the congressional and political oversight and adaptation to newly enacted laws. [2]

Performance has always been an issue and continues to be so into the future. One of the chief reasons is that data has not only risen steady as more sites and locations have joined, but the VA is required to keep all data about a patient for 75 years after the last patient visit! This is even after the patient has died. Even if a patient has been inactive, data needs to be accessible immediately for whatever a provider might need it for.

In 1995, DHCP was crowned as a recipient of the Computerworld Smithsonian Award for best use of Information Technology in Medicine. A year later, the name VistA was officially given to the much improved system after the addition of a Graphical User Interface for providers known as the Computerized Patient Record System (CPRS), written using Delphi.

By 1999, multimedia online patient records were provided in VistA. Images from specialties such as cardiology, pulmonary and gastronintestinal medicine, pathology, radiology, hematology and nuclear medicine were supported.

As of 2001, it was the largest system in use in the US, with medical documentation and ordering available at every VA hospital in the country. In September 2002, 90.6% of all inpatient and outpatient pharmacy orders were entered by the provider. Today, the system is in use in hundreds of hospitals and clinics worldwide, not just in the VA Hospital System.

By 2003, the VHA was the largest single medical system in the United States, providing care to over 4 million veterans, employing 180,000 medical personnel and operating 163 hospitals, over 800 clinics, and 135 nursing homes. About a quarter of the nation's population is potentially eligible for VA benefits and services because they are veterans, family members, or survivors of veterans.

VistA supports several other modules; however, the Bar Code Medication Administration (BCMA) module has been instrumental in ensuring patient safety at VA hospitals. VistA is also used to support Human Resource and Payroll applications.

Mutual development of VistA combined with its integration into the patient care environment as well the capacity to distribute data has made VistA a major contributor to the VA’s accomplishments. [1]

EHR usage

By providing electronic health records (EHRs) capability, VistA is thereby one of the most widely used EHRs in the world. Nearly half of all US hospitals that have a full implementation of an Electronic Medical Record (EMR) are VA hospitals using VistA.

As of 2009, VistA incorporates all of the benefits of DHCP as well as including the rich array of other information resources that are becoming vital to the day-to-day operations at VA medical facilities. It represents the culmination of DHCP's evolution and metamorphosis into a new, open system, client-server based environment that takes full advantage of commercial solutions, including those provided by Internet technologies.

VistA consists of nearly 100 applications, including the Computerized Patient Record System (CPRS) and Barcode Medication Administration (BCMA). A complete description and list of all applications can be found at the Vista website.

CPRS

VistA’s 1996 release of its CPRS aligns well with the current public emphasis in the U.S. on patient-centered health care (1). CPRS is a product that integrates Adverse Reaction Tracking, Bed Control, Consults, Dietetics, Encounter Forms, Order Check Expert System, Inpatient Pharmacy, Laboratory, Order Entry, Outpatient Pharmacy, Problem List, Radiology/Nuclear Medicine, Registration, Scheduling, Text Integration Utilities, and Vitals. CPRS then presents all relevant patient data--including medical history and conditions, problems and diagnoses, diagnostic and therapeutic procedures, and interventions--in a way that directly supports clinical decision making (2). Additionally, CPRS provides electronic data entry, editing, and electronic signatures for provider-patient encounters. Its computer-based provider order entry (CPOE) capability is an important enabler in the migration from paper-based charting to EMRs. On the other hand, CPRS is now up to version 29, underscoring an ongoing reality: that EMR systems are continually evolving CPRS demo. This factor must be considered by providers who have a choice of hosting their own EMR system or going with a monthly fee-based ASP remote-hosting model in order to avoid the hassles of regular updates. Another observation from the VistA CPRS version 29 demo is that even after so many revisions there is a lot of area that need continuous improvement.

CPRS supports the new directions of VISTA, which will increased the focus on ambulatory care, patient access to their medical records, the ability to share and transfer data, track patient's history and treatment over time and track costs [1].

CAPRI

Compensation and Pension Records Interchange (CAPRI) to connect Veteran Service Organizations (VSOs) to VA information resources. It provides VSO authorized agents with read-only access to veteran entire EHR. Additionally, it provide researcher with access to patients EHRs across the nation. Thus, facilitate conducting large research projects. It also help Federal Health Information Exchange and easy access to VistAWeb. CAPRI access implemented on August 2009.

Master Patient Index

There are approximately 140 Department of Veterans Affairs (VA) databases in use across the country in VA facilities that are accessible via VistA systems. Because of this wide distribution of information, there is great potential for individual patient data to be kept under more than one identification number.

The master patient index (MPI) has been created to support maintenance of a unique patient identifier and a single master index of all VA patients, and to allow messaging of patient information among systems of interest to the MPI [i.e., systems of interest are VA facilities where patients are seen for care, non-VistA systems that have a registered interest in a patient (e.g., Federal Health Information Exchange [FHIE], Home TeleHealth, Person Service Identity Management [PSIM], Health Data Repository [HDR], etc).].

The ability to uniquely identify a patient and the facilities where that patient receives care is a key factor in the delivery of quality care. The ability to uniquely identify patients assists in the elimination of duplicate records throughout all VA systems and other agencies, and allows the systems to share information for patients that receive care from more than one facility/agency (4).

My HealtheVet

VA patients can access their medical information online, to enhance partnering with their health care members and make informed medical decisions about their health (4). MyHealtheVet offers three account types:

Basic – this modality provides anyone who registers with My HealtheVet limited access to features in My HealtheVet that permit a user to add information to a personal health journal; record an track personal information and health measurements; print a a wallet ID card with self-entered personal health information and set personal goals. The user can view, save, print or download the self-entered information to share with caregivers or trusted others.

Advanced – this is limited to Veterans and/or VA patients and provides higher level of access to My HealtheVet features that include ability to view VA and/or DoD records

Premium – this is also limited to Veterans and/or VA patients and allows access to key portions of the VA health record (e.g. discharge summaries and diagnostic reports); functionality to save and download information to share with care givers and a secure messaging feature to enable online communication with the VA healthcare team.

BCMA

Inspired by G. Sue Kinnick, a Registered Nurse, and with further investigation, in 1994 a prototype of the BCMA was developed at the Colmery-O’Neil Veterans Affairs Medical Center (VAMC), which is a part of the VA Heartland Network VISN 15 and a division of the Eastern Kansas Health Care System. Since the prototype's inception at the East Kansas Health Care System through March 2001, more than 549,000 errors had been prevented while administering over eight million doses of medications. This was possible by the ability of the prototype to streamline all the processes involved from physician ordering to administration of the medication with system checks and balances in between. Based on this prototype, the BCMA project was initiated in 1998.

The following timeline summarizes the history of VistA (6):

     1992- $50,000 start-up funds provided to the East Kansas Health Care System to test the feasibility of developing a barcoding system for administering medications. 
     1994- The software and hardware design process of the barcoding system prototype was completed via extensive end-user involvement and feedback. 
     1995- The prototype is implemented throughout all 22 nursing units within facilities of the East Kansas Health Care System. 
     1998 (August) - The Bar Code Medication Administration (BCMA) project is initiated. 
     1999 (August) - BCMA is successfully implemented in most of the VA's 172 medical centers nationwide. 

Nurses use this application at the bedside at the time of medication administration. Nurses scan the patient’s identification band using a hand-held device, when the patient's virtual due list populates then the nurse scans the barcode on the medication and subsequently administers the medication per the prescribing physician's orders. There is evidence showing a 70% decrease in medication errors after the implementation of this system at one of the VA sites (3).

Being a system implemented somewhat uniformly across 128 sites, it is noteworthy in its site-specific flexibility. Individual user sites can adopt data dictionaries unique to that site. One important drawback of VistA is that site-specific data dictionaries prevents data summarization between sites, or on a system-wide level. Such data sharing and reporting limitations across sites can be overcome using a national dictionary acting as a cross-reference.

The VA currently runs a majority of VistA systems on InterSystems Caché. VistA can also run on GT.M, an open source database engine for Linux and Unix computers. Although initially separate releases, publicly available VistA distributions are now often bundled with the database in an integrated package. This has considerably eased installation.

"For more than 20 years, the FOIA has been used by nonprofit, commercial and foreign entities to obtain copies of the VistA source code. Through such FOIA requests, versions of VistA are in active use in Finland, Germany, Egypt and Latin America, as well as by a number of state and local health care systems in the United States. Examples of external VistA user organizations can be found in Hardhats.org (2003), Marshall (2003) and Medsphere (2003)." [West, Joel, 2003]

VistA and and AHLTA of the DoD, were the first two largest US Government EHRs built on standardized base of interoperability of patient records. The project objective was to develop an interface between the DoD Clinical Data Repositiry (CDR), and the VA's Health Data Repository (HDR) that support a real time bi-directional exchange of computable health data.

The Veterans Health Administration is currently on BCMA Version 3.0. The latest patch under development is the BCMA PSB.3.0.48 which is the BCMA Backup HL7 Update (8).

Vista Chemotherapy Manager (VCM)

The United States Department of Veterans Affairs (VA) uses many other clinical applications besides CPRS and BCMA. Chemotherapy orders can be very complex and require additional calculations to determine the amount of chemotherapy a patient may receive. Because of this complexity, these orders could not be done through the regular ordering which is using CPRS and BCMA. Until recently, clinicians were using manual calculations to determinate the amount of Chemotherapy.

Solution

A solution has been implemented in many VAs to enhance patient care. DSS.inc developed an application that is being implemented in several VA’s across the country and is called: VistA Chemotherapy Manager (VCM). VCM computerizes the administration of chemotherapy for cancer care. The application facilitates Hematologist/Oncologists the ordering of Chemotherapy.

Clinical Functions

  • Automatically calculates dosages and provides safety alerts during the order writing process.
  • Supports evidence based chemotherapy treatment.
  • Malignancy and associated treatment information is conveniently displayed.
  • VCM allows you to review a Treatment Plan template before you select it.
  • Treatment Plans are order sets that can be created or edited for global use in oncology practice.
  • VCM allows clinicians to review the results of lab tests that have been ordered for the patient.
  • Clinical warnings, such as drug interactions and Dose Reduction Reasons, appear as clear, concise pop-up messages.
  • Physicians can review, edit, and accept an order before it is released to the VistA Pharmacy Package.
  • Treatment Plans are order sets that can be created or edited for global use in your oncology practice.
  • Clinical warnings, such as drug interactions and Dose Reduction Reasons, appear as clear, concise pop-up messages.
  • Locating patient is easy
  • VCM offers VA users functionality in the multidisciplinary VistA environment to improve the standardization of patient treatment and ensure that patient safety issues are addressed.
  • Automatically calculates dosages and provides safety alerts during the order writing process.
  • A Drug Utilization Report template generates a report that provides inventory information that is relevant to your practice.
  • The assignment of a treatment plan can be as easy as selecting it from a list and indicating a Line of Therapy.
  • A list of patients is displayed for the user to select from.
  • Scheduling a regimen is easy because cycles can be viewed across a span of time and edited without technical effort.
  • Allows users to electronically assign and review patient treatment plans that are tailored to oncology practice.
  • Allows chemotherapy orders to be written and transmitted to the VistA pharmacy package without disrupting the pharmacy workflow.
  • Is integrated with VistA/CPRS to provide information necessary for clinical decision making.
  • To write an order are presented with the entire Treatment Plan that has been assigned to the patient. If needed, a treatment cycle order set can be edited before it is submitted.
  • write medication orders using treatment plan templates with only takes a few clicks.

--Carlos J. Perez

Future VistA Challenges

[1]

The VHA is addressing a number of future challenges with a strategy called HealtheVet. Overcoming these challenges will support development of its planned national health data repository (HDR) reducing the storage needs at each VistA implementation. First and foremost is separating data repositories from underlying applications. Secondly, standardization of formal reference terminologies facilitating organization computable and comparable data is required. The third challenge is to keep the current MUMPS database or migrate to a relational or object oriented database.

Migration presents additional challenges. Local VistA implementations store data in MUMPS "globals" volume sets on pre-allocated disk sections. When volume sets exceed 16 GB, performance degrades. This is problematic due to three factors; accelerated data accumulation, 75 year record retention requirements, and the physician demand for availability of all records. The HDR is complicated by prior decisions to allow local implementations to determine data dictionaries for clinical data. This choice supported rapid growth of the VistA programs, but now complicates the national decision support system using data from local terminologies that are not recognized. One further complication is the variability of bandwidth and network reliability.

The federal "HealthePeople strategy" to adopt common data, communications, architecture, security, technical, software standards in federal health information systems (HIS) along with shared software will result in full interoperability.

Recently, the Department of Defense (DoD) released its solicitation to EHR vendors to modernize their electronic health records. The Request of Proposal is valued around 11 billion dollars. Commercial EHR vendors such as Epic system partnership with IBM, Allscripts partnership with HP and Computer Sciences Corporation to compete for the DoD request [2]. Nonetheless, VA secretary Eric Shinseki said that the VA is planning to develop an advanced VISTA that will be equal to commercial software, but he also acknowledged that if DoD new software meet VA need the VA “will go after that” [3].

Additional VistA Resources and Initiatives

VistA Imaging System - Will provide complete online patient data to health care providers at VA health care facilities, increase clinician productivity, facilitate medical decision making, and improve quality of care through the integration of scanned images (e.g. x-rays, ultrasounds, MRIs) linked to documents of patient medical records. Additional forms of imaging media include "video, sound, and waveforms". [3]

VistA Laboratory IS System Reengineering - Will enhance the VA Laboratory Service's information technology system and associated business processes to address current deficiencies and meet future needs.

VistA Legacy - The operating system software platform and technical infrastructure (associated with clinical operations) on which VA health care facilities operate their software applications.

VistA Monograph - is a compilation of the history of VistA and includes an overview of specifically Class 1 software applications supported directly by Veterans Affairs (VA) Office of Information Technology (OIT).

References

  1. 1.0 1.1 Brown, SH, Lincoln, MJ, et al. VistA - U.S. Department of Veterans Affairs national-scale HIS. International Journal of Medical Informatics. 2003; 69:135-156.
  2. Cite error: Invalid <ref> tag; no text was provided for refs named Brown
  3. Complete Multi-media Electronic Health Care Record Integrates Images and Scanned Documents in the Patient’s Chart.
  1. Longman, Phillip. Best Care Anywhere – Why VA Health Care is Better Than Yours. 2007. Poli Point Press
  2. 2008_2009_VistAHealtheVet_Monograph_FC_0309, http://www.va.gov/VISTA_MONOGRAPH/docs/2008_2009_VistAHealtheVet_Monograph_FC_0309.doc
  3. Johnson C. L., Carlson R. A., Tucker C., Willette C., (2002). Using BCMA Software to Improve Patient Safety In Veterans Administration Medical Centers. Journal of Healthcare Information Management. 16 (1), pp.46-51
  4. West, Joel and O’Mahony, Siobhán [1]. 2003
  5. Bar Code Medication Administration Training Web Site: http://vaww.vistau.med.va.gov/VistaU/barcode/default.htm#BCMATrnMat

[1]


  1. http://www.dssinc.com/intrinsiq_intellidose.htm?id=o
  2. http://eon.businesswire.com/news/eon/20111107005281/en/Chemotherapy/Oncology/VA-Medical-Center
  3. http://www.reuters.com/article/2011/11/07/idUS145642+07-Nov-2011+BW20111107
  4. http://code.osehra.org/journal/browse/publication/29#
  5. http://worldvista.org/AboutVistA

  1. http://v16.med.va.gov/apps/GUI/HOU/Clinical/CPRS/Help/CPRS.htm
  2. http://ehrintelligence.com/2014/09/05/pwc-enters-competition-for-dod-ehr-modernization-contract/
  3. http://www.nextgov.com/defense/2014/03/va-competing-pentagons-electronic-health-record-contract/80485/
  4. http://www.ehealth.va.gov/MHEV_keepingthepromise.asp#sthash.02lMSwGp.dpuf


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